The nurse will be using the Braden Scale with each admit to the longterm care center. Which of these will be utilized in a Braden Scale assessment? (Select all that apply.)
Sensory perception
Age
Friction and shear
Nutrition
Mental state
Correct Answer : A,C,D
Choice A reason: Sensory perception is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client can respond to pressurerelated discomfort or pain. Sensory perception can be affected by factors such as level of consciousness, spinal cord injury, or neuropathy. Sensory perception can influence the risk of pressure injuries, as clients with impaired sensory perception may not be able to feel or report the pressure, or change their position to relieve the pressure.
Choice B reason: Age is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Age is a demographic variable that can be associated with other factors that affect the risk of pressure injuries, such as skin condition, mobility, or comorbidities. However, age itself is not a factor that is measured or scored in the Braden Scale assessment.
Choice C reason: Friction and shear is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's skin is exposed to rubbing or sliding forces. Friction and shear can be affected by factors such as bed linens, transfers, or repositioning. Friction and shear can influence the risk of pressure injuries, as they can damage the skin and underlying tissues, or reduce the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Nutrition is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's intake of food and fluids meets the body's needs. Nutrition can be affected by factors such as appetite, dentition, or swallowing. Nutrition can influence the risk of pressure injuries, as it can affect the skin integrity, wound healing, and immune function of the client.
Choice E reason: Mental state is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Mental state is a psychological variable that can be associated with other factors that affect the risk of pressure injuries, such as sensory perception, mobility, or activity. However, mental state itself is not a factor that is measured or scored in the Braden Scale assessment.
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Correct Answer is D
Explanation
Choice A reason: Truck driver is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Carpal tunnel syndrome is a condition that occurs when the median nerve, which runs through the carpal tunnel in the wrist, is compressed or irritated by inflammation, swelling, or pressure. Truck drivers may experience other musculoskeletal problems, such as back pain, neck pain, or shoulder pain, due to prolonged sitting, vibration, or poor posture.
Choice B reason: Nursing assistant is an occupation that increases the risk for carpal tunnel syndrome, but it is not the best answer, because it involves other factors besides repetitive motion that can contribute to the condition. Nursing assistants may perform repetitive tasks, such as lifting, transferring, or bathing patients, that can strain the wrist and the median nerve. However, they may also experience other risk factors, such as trauma, infection, arthritis, or pregnancy, that can cause carpal tunnel syndrome.
Choice C reason: Elementary school teacher is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Elementary school teachers may perform some tasks, such as writing, typing, or grading papers, that can involve wrist movement, but they are not likely to be frequent or intense enough to cause carpal tunnel syndrome. Elementary school teachers may experience other stressrelated problems, such as headaches, fatigue, or burnout, due to the demands of their work.
Choice D reason: Assembly line worker is the best answer, because it is an occupation that increases the risk for carpal tunnel syndrome, due to the nature and duration of the work. Assembly line workers may perform repetitive, forceful, or awkward movements of the wrist, such as twisting, bending, or gripping, that can cause compression or irritation of the median nerve. Assembly line workers may also work for long hours, with little rest or variation, that can exacerbate the condition.
Correct Answer is D
Explanation
Choice A reason: "Because it is easy to digest." is not the best response by the nurse. This is not a valid reason for giving protein supplements to a client with a bed sore. Protein supplements may or may not be easy to digest depending on the type and amount of protein and the client's digestive system. The ease of digestion is not the main goal of protein supplementation.
Choice B reason: "If you don't like it, you don't have to take it." is not the best response by the nurse. This is a dismissive and unprofessional response that does not address the client's question or concern. Protein supplements are prescribed for a reason and the client should be educated on the benefits and risks of taking or refusing them. The nurse should also respect the client's preferences and choices and offer alternatives if possible.
Choice C reason: "These supplements have nothing to do with your wound." is not the best response by the nurse. This is a false and misleading statement that contradicts the evidencebased practice of wound care. Protein supplements have a lot to do with wound healing as they provide the essential nutrients for tissue repair and regeneration. Protein deficiency can impair wound healing and increase the risk of infection and complications.
Choice D reason: "Protein has amino acids that promote wound healing." is the best response by the nurse. This is a factual and informative statement that explains the rationale for giving protein supplements to a client with a bed sore. Protein is composed of amino acids, which are the building blocks of cells and tissues. Amino acids are involved in various processes of wound healing, such as collagen synthesis, angiogenesis, and immune response. Protein supplementation can enhance wound healing and prevent protein malnutrition.
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